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Physician Visit Documentation Form

Physician Visit Documentation Form

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hi guys welcome back to medical coder life today we're continuing our series on physician documentation and we're talking about the history and physical now the purpose of the history and physical examination is to document the health status of the patient at the current time with signs that might aid the practitioner in predicting a diagnosis of the illness or predicting the outcome of the patient's care or both it's the starting point it's when the patient first went into the physician's office and based on the physician the patient's diagnosis the physician felt that better care could be rendered to this patient in the inpatient setting so again history and physical is that first form I call it chapter one of my book that I'm reading because this is my starting point this gives me a current status of the patient today okay what does the patient the physician see that is wrong with the patient today that he feels justifi

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